Söderberg, Stig

Abstract [en]

This study was motivated by encounters with persons with repeated suicidality in clinical psychiatry. Their suicide attempts are frequently regarded as manipulative, and the patients are often labelled a “borderline personality disorder”. They cause frustration and are sometimes met with repellent attitudes among clinicians, but clinical experience as well as research shows that their personal history regularly includes severe childhood trauma and often childhood sexual abuse.

The first part of the study was undertaken to investigate the frequency of borderline personality disorder among consecutive persons admitted to hospital after a suicide attempt, the experience of adverse life events among them and the motives for the act. The concept and definition of parasuicide was used as inclusion criterion. During the 10 months of the study 81% of all parasuicide inpatients gave their consent to partake, altogether 64 patients, 41 women and 23 men. Standardized instruments were used for assessment of personality disorders, and self-report questionnaires were used to investigate motives and adverse life events.

Seven years later, follow-up interviews were conducted with 51 of these persons, 32 women and 19 men. This second part of the study used qualitative methods in the form of thematic open-ended interviews to allow for the patients’ own descriptions of their suicidality and mental health in the years following the suicide attempt. The role of psychiatry in this process was one of the themes in the interview. Use of psychiatric treatment and support during the follow-up period was investigated through a review of the medical charts recorded at the psychiatric clinic.

The quantitative part of the study showed that among the parasuicide patients there was a considerable overrepresentation of borderline personality disorder, and that the frequency of adverse life events was much higher in this subgroup. The motives for the parasuicide did not differ between those with borderline personality disorder and the others. Childhood sexual abuse could be identified as the most important factor influencing suicidality and extent of psychiatric treatment after the index parasuicide.

The patients’ own descriptions in the follow-up interview were related to the theoretical perspectives of symbolic interactionism, therapeutic alliance, perception of difference, empowerment and the concept of modernity. In the narratives a picture emerges of a psychiatric health care that carries the potential to offer therapeutic relationships, but often fails in its aims. In therapeutic alliances built on personal relationships, characterized by close and frequent encounters and a focus not only the weaknesses but also the strengths of the patient, there was room for personal development. A reliance on therapeutic method instead of a therapeutic alliance with the patient and a lack of a collaborative perspective in therapeutic work set definite hindrances for the therapeutic process, according to the views of the patients.

Regardless of the severity of the life experiences and personality dimensions that had lead to the parasuicide, the core prerequisite for subsequent stabilisation was an orientation towards significant others that saw and supported the potential for change and helped redefine the situation. These significant others were sometimes found in the psychiatric health care services, but were mainly found outside of psychiatry.

The conclusions of the study are that there is a close correlation between repeated suicidality, borderline personality disorder, female gender and adverse events such as childhood sexual abuse, and that the repeated suicidality is better explained by adverse events such as childhood sexual abuse than by personality disorder. This background seriously challenges repellent attitudes towards these patients. The narratives of the patients pose definite challenges for the therapeutic community to embrace new ways to find working therapeutic alliances after a parasuicide, possibly based around perspectives of empowerment and mutuality. Identifying the processes that helps the person find “the difference that makes a difference” should be in focus of future psychiatric research and at the heart of psychiatric support and treatment after parasuicide, to enable the patients to find their own strengths and resources and in this way be able to leave it all behind.